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Clark Atlanta University Center for Cancer Research and Therapeutic Development Prostate Cancer Symposium July 17th, 2010 Prostate Cancer Treatment: What’s Best For You? Rajesh G. Laungani, MD Director, Robotic Urology Chairman, Prostate Cancer Center Saint Joseph’s Hospital, Atlanta 2008 Estimated US Cancer Cases* Prostate 25% Lung and bronchus 15% Colon and rectum Men 745,180 Women 26% 692,000 Breast 14% Lung and bronchus 10% 10% Colon and rectum Urinary bladder 7% 6% Melanoma of skin 5% Non-Hodgkin 5% 4% 4% lymphoma Kidney 4% Leukemia 3% Oral Cavity 3% Pancreas 3% Uterine corpus Non-Hodgkin lymphoma Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2008. JEMAL ET AL. CA CANCER J CLIN 2008 2008 Estimated US Cancer Deaths* Lung and bronchus 31% Prostate 10% Men 294,120 Women 26% 271,530 15% Lung and bronchus Breast Colon & rectum 8% 9% Colon and rectum Pancreas 6% 6% Ovary Leukemia 4% Esophagus 4% Liver and intrahepatic bile duct (IBD) 4% Non-Hodgkin 3% Lymphoma Urinary bladder 3% Kidney 3% 6% 3% 3% 3% Pancreas Leukemia Non-Hodgkin lymphoma Uterine corpus 2% Liver & IBD 2% Brain/ONS ONS=Other nervous system. Source: American Cancer Society, 2005. JEMAL ET AL. CA CANCER J CLIN 2008. Approach To Treatment of Prostate Cancer: A Multidisciplinary & Individualized Approach External Beam Radiation Open Surgery Brachytherapy Robotic Surgery Watchful Waiting Treatment Options for Prostate Cancer • Active Surveillance • Radiation Therapy – External Beam – Brachytherapy aka “seeds” – HDR Therapy – Proton Therapy • Hormonal Therapy • Chemotherapy • Surgery – Robotics – Laparoscopic – Traditional Open • Retropubic • Perineal – Cryosurgery – HIFU “One Size Does NOT Fit All” • • • • • Age Gleason Grade Stage Co-Morbidities Individual Characteristics What does a positive biopsy mean? Gleason Grade Gleason 6 Gleason 10 7 8 9 LOW GRADE HIGH GRADE Staging • Clinical: – – – – DRE CT Scan Bone Scan MRI • Pathological: – – – – Margins Lymph nodes Extracapsular Extension Seminal Vesical Invasion STAGE SUB-STAGE T1 T4a T4b Clinically unapparent tumor, not detected by DRE nor visible by imaging Incidental histologic finding; <5% of tissue resected during TURP Incidental histologic finding; >5% of tissue resected during TURP Tumor identified by needle biopsy due to elevated PSA Confined within the prostate (detectable by DRE, not visible on TRUS) Tumor involves half of the lobe or less Tumor involves more than one half of one lobe but not both lobes Tumor involves both lobes Tumor extends through the prostate capsule but has not spread to other organs Unilateral extracapsular extension Bilateral extracapsular extension Tumor invades seminal vesicle(s) Tumor is fixed or invades adjacent structures other than seminal vesicles Tumor invades bladder neck and/or external sphincter and/or rectum Tumor invades levator muscles and/or is fixed to pelvic wall SUB-STAGE DEFINITION N0 N1 N2 N3 Regional lymph nodes No lymph nodes metastasis Metastasis in single lymph node <2 cm in greatest dimension Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm Metastasis in lymph node >5 cm in greatest dimension SUB-STAGE DEFINITION T1a T1b T1c T2 T2a T2b T2c T3 T3a T3b T3c T4 STAGE Node (N) STAGE DEFINITION Metastasis M0 M1a M1b M1c Systemic spread No distant metastasis Non-regional lymph node metastasis Bone metastasis a) Axial skeleton only b) Extending to peripheral skeleton also Metastasis at other sites Robotic Surgery • Decreased Pain • Shorter Hospital Stay • Decreased Blood Loss • Quicker Recovery • Improved Quality of Life after Surgery Current Trends U.S. Robotic Prostatectomy Trends 80000 70000 60000 48,000 50000 32,631 40000 30000 17,582 20000 10000 36 247 766 2648 8,642 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 36% 63% Robotic Prostatectomy Do Advanced Tools result in Better Outcomes ? Vision and Control How do attributes of robotic surgical systems translate into outcomes? • Operative parameters • Oncologic parameters • Quality of life parameters • Potency & continence Urinary Continence • • • • • • • Joseph et al. 2006 N=325 Mean age: 60 Method of Assessment: Questionairre Definition used: No pad Time of assessment: 6 mos Continence Rate: 96% Joseph et al. J Urol 2006 Bilateral Nerve Preservation Technique “The Veil of Aphrodite” • • • • • • • Menon et al. N=250 Mean age: 59.9 Method of Assessment: Questionairre Definition used: Intercourse Time of Assessment: 6 mos Potency Rate: 64% Menon et al. Urol Clin of Amer 2004 Oncologic Efficacy • • • • Badani et al. N=2766 Gleason 7 or >: 64% Median follow up: 22 mos – PSA recurrence rate: 7.3% • 5 year biochemical free survival: 84% Badani et al. Cancer 2007 Robotics vs. Open vs. Laparoscopic Parameter RRP LRP daVP Op time (min) 164 248 140 Blood Loss(ml) 900 380 <100 Positive Margins 12% 24% 8% Complications 15% 10% 5% Catheter(d) 15 8 5-7 Hospitalization 3.5 1.3 1.2 How do I choose the best surgeon? What questions should I ask? • • • • • Training? Fellowship? Experience? How many cases have you done? Reputation? • Having a robot and knowing how to do robotic surgery are very different things? Steady and Experienced Behind the Wheel Thank You